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Topic: two commercial insurances (Read 3856 times)

i was always taught ( not sure right though) that if patient and spouse carry insurance it goes by who's every birthday comes first is primary ? someone told me this applies only to children not adult insurances ?? what do guys no about what is correct. patients don't always know.

No, it's straight forward with just the spouses, each one covers themselves primary, then secondary is determined by first making sure the other is a dependent on that policy. The birthday rule (if applied, not all use birthday rule) comes into factor with the dependents/kids

Pay_My_Claims

No, it's straight forward with just the spouses, each one covers themselves primary, then secondary is determined by first making sure the other is a dependent on that policy. The birthday rule (if applied, not all use birthday rule) comes into factor with the dependents/kids

THAT IS NOT TRUE!!! If I have an individual policy and my husband carried me on his group plan, his plan is PRIMARY and mines is SECONDARY!!

Pay_My_Claims

LOL @ Brain Fart........we all have them just didn't want the poster leaving with misinformation. COB was a PRIORITY at the hospital I was employed at, especially when Medicare was involved. I had to audit cases on a daily basis before we sent the claims out. This is whats so great about this business. We dabble in so much and when tied together correctly, it makes a nice flow..

Coordination of benefits (COB) is the procedure used by benefit carriers to pay health care expenses when a patient is covered by more than one plan. Determining the primary carrierTo determine which plan is primary, find out if the patient is the subscriber or a dependent and any special COB rules the other plan may have. The primary carrier must meet at least one of the following conditions:

1. The plan has a no-COB clause If the other group plan does not coordinate benefits, it is primary.

2. The patient is the employee (subscriber) The plan covering the patient as an em¬ployee (subscriber) is always primary over a plan covering him/her as a dependent, retiree, or COBRA-qualified beneficiary. If one person is the subscriber for both plans, the plan covering him/her as an active member is primary. If the subscriber is considered an active member under both plans, the plan covering him/her the longest is primary.

3. The patient is a dependent child The birthday rule. Under the birthday rule, the plan of the parent with the first birthday in a calendar year is always primary for the children. For example, if the mother’s birthday is in January and the father’s birthday is in March, the mother’s plan is primary for all of their children. If one of the parent’s plans has a conflicting coordination rule (such as a gender rule that says the father’s plan is always primary),

4. The patient is a dependent child of divorced or separated parents If a court decree makes one parent responsible for health care expenses, that parent’s plan is primary. If a court decree does not identify who is primary, the order of liability depends on the legal custody of the child as follows:

Federal Law requires that employers offer to their employees age 65 or over the same coverage offered to employees under age 65. If the employer offers health care coverage to spouses, the same coverage must be offered regarding of age. This equal-benefit rule applies to coverage offered to full-time, part-time employees, or retirees.

Medicare beneficiaries are free to reject employer plan coverage, in which case they retain Medicare as their primary coverage. When Medicare is the primary payer, employers cannot offer such employees or their spouses a supplemental plan that pays for services covered by Medicare.Where a GHP is the primary payer but does not pay in full for the services, Medicare becomes the secondary payer and pays for Medicare-covered service up to the Medicare approved amount. If a GHP denies payment for services because they are not covered by the plan, Medicare may pay, for services covered by Medicare.

Medicare is secondary payer to group health plans (GHPs) for the following groups of Medicare beneficiaries: working aged, certain disabled individuals, and individuals with End-Stage Renal Disease/permanent kidney failure.

Working AgedWorking aged are beneficiaries age 65 or over who have GHP coverage because of their current employment or their spouse’s current employment. For the working aged, Medicare is secondary payer for claims to the GHP. For the purposes of the MSP Working Aged provision, a GHP is any health plan that is for, or contributed to by, an employer of 20 or more employees that provides medical care, directly or through other methods, such as insurance or reimbursement, to current or former employees and their families.

The "20 or more employees" threshold is met when an employer has 20 or more full-time and/or part-time employees for each working day in each of 20 or more calendar weeks in the current calendar year or the preceding calendar year. The 20 calendar weeks do not have to be consecutive. The requirements of the MSP Law are based on the number of employees, not the number of individuals covered under the plan.

DisabilityMedicare is secondary payer for claims for beneficiaries under age 65 who have Medicare because of a disability and who are covered under a large group health plan (LGHP) through their current employment or through the current employment of any family member.A GHP that covers employees of at least one employer that had 100 or more employees on 50 percent or more of its business days during the preceding calendar year meets the definition of an LGHP. The LGHPs include plans sponsored or contributed to by an employer or employee organization (such as a union), as well as plans in which employees pay all the costs. The plan provides health care to employees, former employees, the employer, or their families, and covers at least 100 or more full-time and/or part-time employees.

End-Stage Renal Disease/Permanent Kidney FailureFor individuals who have Medicare entitlement or eligibility because of permanent kidney failure, during the first 30 months of that eligibility or entitlement, the GHP must be the primary payer. This requirement applies to both those with permanent kidney failure who have their own coverage under a GHP and to those covered under a GHP as a dependent.The GHP is primary to Medicare during the periods described below. This rule applies without regard to the number of employees and without regard to the enrollee’s employment status. The period for which the GHP is the primary payer begins with the earlier of:

No-Fault and Liability InsuranceNo-fault insurance is insurance that pays for health care services resulting from bodily injury or damage to property regardless of who is at fault for causing the accident. Types of no-fault insurance include but are not limited to automobile insurance, homeowners’ insurance, and commercial insurance plans.Liability insurance is coverage that protects against claims based on negligence, inappropriate action, or inaction that results in bodily injury or damage to property. Liability insurance includes but is not limited to homeowners’ liability insurance, automobile liability insurance, product liability insurance, malpractice liability insurance, uninsured motorist liability insurance, and underinsured motorist liability insurance.

Federal Law Takes Precedence Over State Law and Private ContractsMedicare is the secondary payer of claims when no-fault or liability insurance is available as the primary payer, even though state law or the insurance plan or policy states that its benefits are secondary to Medicare or otherwise excludes/limits its payments if the injured party is also entitled to Medicare benefits. With the exception of conditional payments as discussed belwo, no Medicare payments are made when payment has been made or can reasonably be expected to be made by the no-fault or liability insurer, and until no-fault or liability insurance has been exhausted. A provider or supplier may not collect payment from a beneficiary until after the proceeds of the no-fault or liability insurance settlement are available to the beneficiary.

Medicare can Make Conditional PaymentsIf it is determined that the no-fault or liability insurer will not pay "promptly" (within 120 days), providers and suppliers may submit claims to Medicare, and Medicare may make a conditional payment. However, when the proceeds from the no-fault or liability settlement become available, Medicare has priority right of recovery. This means that Medicare collects the money it used for the conditional payment from the settlement before other providers and suppliers may collect from the settlement.After that 120-day period, a provider or supplier may choose to bill Medicare conditionally. In a liability insurance situation, if the provider/supplier chooses to bill Medicare, they must withdraw claims against the liability insurer and any liens placed on the beneficiary’s settlement. If they choose to continue their claim against the liability insurance settlement, they may not also bill Medicare.

***Commercial Insurance/Medicaid: Medicaid is ALWAYS the "payer of last resort" and will always be billed secondary to a commercial insurance or Medicare.********

3. The patient is a dependent child The birthday rule. Under the birthday rule, the plan of the parent with the first birthday in a calendar year is always primary for the children. For example, if the mother’s birthday is in January and the father’s birthday is in March, the mother’s plan is primary for all of their children. If one of the parent’s plans has a conflicting coordination rule (such as a gender rule that says the father’s plan is always primary),

To add to the 'birthday rule'...if both parents are born on the same day and date, then it is the parent whose health ins has been in effect the longest that is the primary

This morning was an all around brain fart, apparently I gave my daughter a $50 bill instead of a $10 bill I think I'm just brain fried this week!

The ironic thing is I've written articles and even a manual for the last insurance company I worked for on Coordination of Benefits, when I was a tech there I was the one everyone went to with COB questions. LOL

The great thing about COB is that sometimes it's not that difficult and before you go digging into the books.. make a phone call, MOST times (guessing 90%) the carriers have already an established order of coverage. I always make the phone call first, much simpler!

Thank you all for your answers !!!!!!!!!!!! Greatly appreciated. The patient is an employee COB and is also covered under her husbands retiree benefit. Turns out both carriers paid as primary and neither carrier knew they had other insurance. So i will call the patient and have her call her secondary carrier to correct this.